Provider Demographics
NPI:1790870236
Name:YAMAZAKI, KIYOMI (DDS)
Entity Type:Individual
Prefix:
First Name:KIYOMI
Middle Name:
Last Name:YAMAZAKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 W GARDENA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4823
Mailing Address - Country:US
Mailing Address - Phone:310-327-9130
Mailing Address - Fax:310-327-9146
Practice Address - Street 1:1143 W GARDENA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4823
Practice Address - Country:US
Practice Address - Phone:310-327-9130
Practice Address - Fax:310-327-9146
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52484Medicaid